Are Graston and Active Release Technique (ART) a Legitimate Treatment For Running Injuries?

Soft tissue injuries are the broadest and most common category of injuries that runners suffer from. This category encompasses all injuries to the muscles, tendons, and fascia in your lower body.

While they are often easier to treat and less severe than “bony” injuries like stress fractures, soft tissue injuries like Achilles tendonitis, plantar fasciitis, and muscle strains nevertheless cause huge disruptions in the training of many runners.

As such, any progress on treating these injuries is sure to garner a lot of attention.

Two relatively new treatment protocols, Graston Technique and Active Release Technique (ART), have emerged as popular ways to speed the healing process from muscle, tendon, and fascia injuries, especially in the running and triathlon communities.

But what kind of scientific support do these treatments have, and are they grounded on good medical information?

To answer that, we will have to review some of the scientific literature that has been published on Graston and ART.

Graston and ART: An overview

Before doing that, however, we ought to become familiar with both Graston and Active Release Technique. Both of these treatments are based on the idea of tissue adhesion and scar tissue—according to proponents of ART and Graston, injured tissue develops abnormalities when it heals, which impair normal function.

To get rid of these abnormalities, ART and Graston both use mechanical force to break them down—ART involves the practitioner using his or her hands to apply pressure to the muscles surrounding the injured area, while flexing and extending the joints they are connected to.

Graston involves using curved metal tools to apply pressure and friction across the injured muscle, fascia, or tendon. Both are “proprietary” techniques, meaning that a practitioner must pay for special classes to become licensed in them.

This naturally attracts some skepticism from the medical and scientific communities, as the nature of the respective businesses, which oversee ART and Graston is somewhat out-of-step with treatments under serious consideration for rehabbing injuries. Perhaps because of this, most practitioners of ART and Graston are chiropractors, though some physical therapists are licensed as well.

Are Graston and ART based on legitimate principles?

Structural changes in tissues affected by chronic overuse injuries are well-documented: The collagen fibers of the Achilles tendon, for example, which appear like wavy, parallel lines when healthy, rupture, snarl, and degenerate into a mess that looks like a plate of spaghetti in athletes with chronic Achilles problems. And the formation of scar tissue in muscle injuries is well-documented, as well.

Additionally, successful treatment of tendon injury through well-vetted rehab programs, such as eccentric heel drops for Achilles tendonitis, is connected with a return to normal tendon structure, at least as measured by ultrasound imaging.

Unfortunately, there’s no good evidence yet that ART or Graston (or any soft-tissue manipulation therapy) can influence the microscopic structure of a healing tendon or muscle in an athlete.

Two studies using different manual techniques found some changes in the structure of rat tendons and ligaments, but this is not nearly enough to declare the theoretical foundations of ART and Graston to be sound.

The best science on these therapies so far is limited to case studies and pilot studies. A case study is the scientific equivalent of an anecdote—they describe how a doctor or therapist treated one particular patient with an injury. Pilot studies are generally conducted with only a few subjects and no control group.

In one example, 20 men took a sit-and-reach test for hamstring flexibility, then had ART administered and underwent another sit-and-reach test, which showed an improvement in hamstring flexibility. In another study, five subjects with carpal tunnel syndrome were treated with ART over a period of two weeks and all demonstrated improvement.

Not all pilot studies found success, though—one study of nine athletes with “anterior knee pain” (likely patellofemoral pain syndrome or ‘runner’s knee‘) found that administering one treatment of ART did not result in better knee function.

All peer-reviewed studies on Graston technique to date are limited to case studies, describing individual patients being treated for everything from trigger finger to low back pain.

Breaking the barrier

The biggest barrier to ART and Graston being accepted as legitimate treatments for injury is the lack of well-designed studies on their usefulness. Control groups, which are administered a fake treatment, are absolutely necessary to establish the scientific worth of any injury rehab protocol. Otherwise, factors like the placebo effect and simple healing over time make determining the use of a treatment near-impossible.

While having a scientific basis for treatments is important, the old adage that “any medicine that works is good medicine” holds up.

Today, most insurance companies will pay for chiropractic adjustments for low back pain, not because chiropractic is necessarily based on solid science, but because well-designed placebo-controlled studies have demonstrated that it is a legitimately beneficial treatment for back pain.

While popular among athletes, the usefulness of ART and Graston is still questionable from a scientific perspective. If you think you might benefit from them, feel free to try it out, but do realize that you are taking a gamble on an uncertain treatment. If you are skeptical, you may want to wait until better-designed studies are published on the benefits of soft-tissue manipulation.

When I was having hip issues this worked very well for me last year. It also was helpful but less so for achilles issues. If nothing else it is a better option to at least try before surgery or more extreme remedies.

Great article. Thanks for publishing this. I have had Graston and another similar technique (ASTYM) applied to several injuries including Achilles tendonosis, Plantar fasciitis and Hamstring insertion tendonosis. These techniques are derivations of ancient Chinese medicine (GuaSha) and a Google search will show just how controversial the effectiveness of these techniques are. In my particular case, I have experienced great results (almost immediate relief) with my Achilles and Plantar issues but not for the Hamstring issue. Additional factors that may determine success include (1) the technique used by the practitioner, (2) the frequency of treatment (3) compliance of the patient with instructions not to aggravate the injury between treatments and (4) accessibility of the technique to the injured tendon (closeness to the skin surface).

After a vicious cycle of more than a year (and nearly resigning myself to a ‘new normal’ which consisted of varying degrees of PF discomfort / pain), I tried ART at the recommendation of a runner friend. It was one of the most painful therapies I have endured, but within a month, I could hardly remember which foot had the problem. Had similar success more recently w/a calf / Achilles injury, and would recommend it as a consideration for any similar connective tissue issue.

I had a 4 cm tear in my hamstring and after 2 months of all the conventional physiotherapy treatments such as ultrasound, hot and cold laser, ice, heat, stretching, I was still stiff and in pain and not running well or for long. From the advice of an ultra-ironman athlete- I went to have the Graston and ART done. After 3 treatments, I was pain free and back running. I felt immediate relief with the very first treatment which I never felt with the conventional treatments. I was told with that kind of tear, that it would take up to a year to be back to “normal”. I was simply amazed with the results in such a short time.

Yes the pain was intense on the injured hamstring and I asked if that was just normal, but when he did the Graston on my other hamstring, it did not hurt at all and moved like a knife through butter. The injured leg felt like the tool was moving over pebbles, and yes, it was painful, but gradually that feeling disappeared and along with the pain. I am a firm believer no matter what any research says.

I lift weights and started late in life. I’ve gone through shoulder impingements, tennis elbow (in both elbows), and golfers elbow in both elbows as well as hip issues when squatting.

I was desperate and tried several things. I finally went to someone who was strongly recommended by several people who performed both ART and Graston on me (at 2 different times, for 2 different problems) and I can honestly say they helped. I am a skeptic. I tried supplements, DMSO, rehabilitation exercises and nothing helped to the same level as ART and Graston.

What made me a complete 100% believer is when I had tennis elbow in both elbows with roughly the same amount of discomfort I decided to get ART done on one, and leave the other to heal on its own. The one that I had ART done done (and graston) healed in half the time of the other – roughly 3 months compared to 6. Also, the long running hip tightness I had while squatting was permanently cured after just one session.

Personally, I don’t think ART will work for everything but for the things it works for it really does work. Also, I am not convinced that it works for the reasons that commonly believed – i.e breaking up scar tissue. I think thats a theory – I think it could be due to something else, like reinjuring the area around the original injury to cause the body to continue working at healing it. Regardless, it does work and I would always try it before considering more invasive or time consuming treatments such as surgery or long term physio.

I’m a Physical Therapist and our clinic utilizes the Graston method with fairly good success. It seems to depend on the nature of the injury, the skill of the user, and the patient’s ability to tolerate the inevitable discomfort that comes with treatment. When I started working at the clinic I am with now, I was very skeptical of the weird metal tools that were lubed up at rubbed on people. I am pretty selective in terms of when I use them and how, but they do seem to help in many cases. I seem to have the best success with work on the neck muscles (upper traps, cervical paraspinal musculature) and plantar fascia work. In fact, some of my patients who rave about Graston the most are….you guessed it…..my runners. In the end, Graston is another tool in the toolbox. If you use the tool in the right way, for the right application, it seems to work well enough. I’d love to see some formal studies though.

Thanks for your input! That is exactly the kind of feedback others will want to see. It is good that you are selective with your usage of it, and that you have found it helps most who are able to tolerate the discomfort. Thank you for sharing. Keep checking back, we will keep researching!

Hi Anna, we cannot help you with that specifically, but if you ask your doctor, they should be able to tell you where the closest place is. Or if you can use google to search for it. Just make sure you check out the place and hear some reviews before going, the individual needs to be certified to treat you correctly. Sorry we could not help more.

Was Reading this article when I saw your comment. I am a Physio Practicing in Mumbai, India. I am Advance Certified in Graston Technique and have been in-serviced in ART. I use both these techniques extensively and have had good results with them.
You can contact me @ 9619004645 or my email:hemaliphysio@gmail.com. Hope this helps!

I gave ART a try for a long time. It did not do what it claimed to do for me. When I brought it up they just said how about some free sessions. The ART practitioner also had an elitist attitude and did not want to help non-athletes. The clinic continually bragged about how they treat athletes that would come in once in a while. I think it was a marketing gimmick. I am glad that it works for some people. I would also suggest seeing a medical doctor.

Hi Stacey, sorry to hear you did not find ART worked. As we said in the post, there has not been too much evidence that it should be relied upon yet, but if individuals do find it helps, then that is great. Have you found other forms of treatment helped better?

His I have been told that I have hamstring tendonophy in my left hamstring will art help me get back to running at the moment it’s now been two years and physio acupuncture stretching etc doesn’t work please help
I live in south East London near tower Bridge if you no of any art or Grafton people

Have been suffering chronic pain from a shoulder injury since last December. Haven’t gone a single day without my arm throbbing. Sleeping had become miserable. Lifting anything so much as a plate, pushing open a door, or putting on a seatbelt, etc. would leave my shoulder extremely sore and irritated.

I started seeing a chiropractor for the first time in my life for an entirely different problem: mid-back pain. With a screwed up left shoulder and a herniated disc (l5-s1) with sciatic pain radiating in my lower back and right side, my mid-back got out of whack due to all of the over-compensating.

My chiropractor, who has two slap tears himself from martial arts training, performs the Graston Technique on my shoulder.

I call my wife after my appointment and tell her I feel like I have experienced a miracle. No pain when putting on my jacket. No pain picking up my kids and tossing them into the air. No pain lifting 24 bags of mulch.

Range of motion returns. I wake up the next morning and my arm isn’t throbbing from laying on it when I sleep.

Next visit, Graston again.

If you’re skeptical, and I am one of the most skeptical people you’ll ever meet, I suggest giving it a try.

It may save you $30,000 and 6-9 months of sling time and rehab.

I met with the surgeon and told him about it. He told me not to tell anyone. Otherwise, he wouldn’t have anyone to operate on.

Will my SLAP tear ever heal? No. But I’m not in chronic pain anymore which makes me enjoy life much more.